Tuesday 22 August 2017


I don't typically think of my job as dangerous.  Quite the opposite, actually - the trauma bay is supposed to be a safe place where people who have done something particularly dangerous and/or stupid come to get something fixed.  Whenever we get a rowdy patient (who is usually either A) drunk, B) high on PCP, C) an asshole, or D) some combination of the above), everyone in the trauma bay knows that, with one quick phone call, several very burly men who could easily pass for moderately large bears will descend upon the asshole and defuse the situation in approximately 4.72 seconds. 

Sometimes, however, even that isn't enough. 

Unlike the trauma bay, prisons are violent places, and violent things tend to happen there.  Granted my information regarding the violence inherent in the penal system is mostly limited to what I learned in The Shawshank Redemption and O Brother Where Art Thou, but that knowledge base expanded significantly recently when I met Ervin (not his real name™). 

I don't usually get too worked up when my trauma pager alerts me to an impending "assault".  That may sound callous, but it's for several good (I think) reasons: 1) When people are assaulted, it is most commonly limited to the face, 2) if these people suffer any injuries (past lacerations and contusions), it is most often a broken nose or other facial bone, 3) those fractures rarely require surgical intervention, and 4) if they do, I call the maxillofacial surgeon to do it.  So when my pager alerted me to an assault arriving in 8 minutes, I sighed and put away the blog post I had been trying diligently (yet failing miserably) to make sound less stupid. 

But then something caught my eye - the patient was arriving by air, not ground.  Hm.  That could mean it was more serious than I was imagining.  Or it could mean the patient was injured further away than an ambulance could drive in a reasonable amount of time.  Or it could mean something else.  Yes, the dreaded "other".  

And of course it was "other". 

When Ervin was wheeled in, the first thing I noticed was the prison jumpsuit.  The second, third, fourth, and fifth things I noticed were the various handcuffs and shackles pinning him to the stretcher.  The next thing I noticed was the mask over his face (think Hannibal Lecter).  Finally came the bevy of police officers accompanying him.  This bodes poorly, I thought. 

And I didn't even know the half of it yet. 

"Hi there, Doc. This is Ervin.  Ervin has been (god damn it Ervin, stop fighting!), uh he's been tussling with the prison guards for the last (damn it, Ervin! Stop fucking spitting!), um for the last two days.  He's being transferred, and (fucking hell guys, he's trying to claw my arm again!), he's being transferred to another facility and doesn't want to go I guess." 

Imagine trying to wrangle a cat into a pet carrier.  Now imagine the cat is extremely angry.  Now also imagine that cat is 2 meters tall, weighs 110 kg, and can curse constantly.  Yeah, that's Ervin. 

He was covered head to toe in abrasions and contusions, and he had obviously earned every single one of them.  Ervin continued fighting as we moved him to our stretcher, and I've rarely seen such a relieved medic crew get the hell out of my trauma bay so quickly.  The officers, on the other hand, thankfully stayed. 

"You want us to uncuff him, Doc?" one of the officers asked me. 

"Hey wait," one of the nurses said.  "I know this guy!  Yeah, Ervin!  He was here as an 'assault' two days ago after he fought with the prison guards!  He injured two techs and a nurse, and he tried to kick me in the face!" 

The police officer looked at me askance. 

Uncuff him? Seriously? 

"Hell. Fucking. No.  Under no circumstances.  NO."  Yes, those were my exact words. 

The tech moved towards him to place an IV, and I immediately stopped her.  I made it clear to everyone in the room that no one was to come near this guy with anything sharp, and all we were going to do was get a quick 5-second CT scan of his brain, see that it was normal, and then send him right back from whence he came.  Fortunately when we brought Ervin to the scanner, he decided the CT doughnut wasn't as threatening as a roomful of cops, so he stayed still long enough for me to see a normal brain. 

Thank you for this one small thing, Call Gods

As I was chatting with a few of the guards a short while later, one of the nurses beckoned to me.  "The radiologist is on the line for you.  He has a critical finding he needs to tell you about." 

Oh come on, no. No. NO. 

It turns out I had missed a tiny subdural haematoma and an even tinier cerebral contusion.  I looked at the scan again and still couldn't see it, so I had another radiologist look at it.  He confirmed that I was indeed not a radiologist and the other radiologist is.  The finding was, in fact, real.  

God. Damn. It. Fuck You, Call Gods. Fuck you. 

So now I was obligated to admit this asshole, put an army of security guards and police officers on him, start an IV, try to do neuro checks on him every hour, repeat the CT scan in a few hours . . . 

Fuck. Just, fuck. 

I did exactly that, apologising to everyone involved in the process.  No one wanted to take care of Ervin, though we all did dutifully and respectfully.  Ervin, however, was not nearly as accommodating.  There were two very large police guards inside his room at all times, and fortunately his outbursts were mostly limited to hurling verbal abuse at anyone he could see.  

The following day his repeat CT scan was stable, his neuro exam was stable (read: he was still a violent asshole), and I kicked him the fuck out of my hospital before he could injure anyone else. 

I have no doubt I will see him again. Soon.


  1. Good read before work, thanks doc.. I imagine it was like herding cats is a favorite saying for the chaos.. And when I would try to load one of my angry 15 pound beasts in to her carrier it was on, the vet knew it was on and the poor vet tech..

    1. big carrier on end, scruff the cat and drop it in, being careful not to catch the feet on anything. (anyone who tries to support a cat's feet while you are trying to control it by scruffing it deserves to have the cat thrown at them. )

  2. ok imma going to brag here.

    I worked with animals for 15 years on anything from rats and mice right up to fucking big baboons with inches long teeth and no manners, farm animals and such like.
    In all those 15 years i got bit twice and both of them were by accident.
    One was when a dumb mutt got his paw stuck in a fence and went to bite it and caught me and the other was a bully dog who bullied once too often and the other dogs beats his ass, including one trying to castrate him with his teeth. he went to bite the other dog caught me barely breaking the skin and the whole pack of dogs suddenly froze as he had done the ultimate no no and nipped the pack alpha (me)
    All my pets have been vet friendly, wingnut in particular sickeningly so.
    I have always handled them as a vet would and trained them (yep i train cats) with key words so when it comes to vet time, said vet (a nice hunky kiwi) tells them what he is going to do, gives the appropriate keyword, toofers, hiya (left paw) hello (right paw) and wherever else he needs to prod and poke and my 3 cats sit there or stand that happy as larry and get a treat at the end as they walk back into their carriers, even my semi feral who ended up with as the original owner got a puppy and said kitty didn't like it and tried to revert to feral and failed.

    Also cos i are a dumb Brit, on vacation to Houston my friends thought it would be fun to take me to a huge pond filled with turtles, nutria rats and sundry birds with large beaks, all wild.
    Me being me was hand feeding the nutria rats as well as the birds. My mate was taking pics to show the Dr. which one bit me.
    I remained unbitten much to their surprise and that of the crowd which had gathered as my friend apologized for the behavior of said dumb Brit.

    Do you ever wish such patients would have horrible things happen to them especially when they go after your staff?

  3. I've had paramedics suggest that patients frequently become more tractable if they stop breathing on their own.

  4. Wait Doc -- you forgot to give us the science/legal bits!

    Wherever you practice, it's not in the US, not with measurements like "2 meters tall, weighs 110 kg". So whatever other English-speaking western democracy you're in, what rights & obligations do YOU have as the head of the ER when there's a patient in need of care who's trying to fuck you up?

    Can you give a dangerous patient a shot of sedative, work on him as needed, then send him elsewhere once he's stable? Here, people in psyche wards can be sedated against their will if they become violent. Do ER docs have that same right where you are if it's not a psyche case?

    I can't fathom how a doctor manages to examine & treat someone who is actively trying to harm you. Esp. when you also have to be responsible for the safety of your staff.

    1. This comment has been removed by a blog administrator.

    2. Tsk tsk, both of you. Please remember one of my major rules.

  5. Here in the states (west side) the hospital only does weights in kilos and heights in meters and centimeters, they have to because of the math of medications in figuring out doses for micrograms and milligrams. My doctor's office does it too, along with every major hospital I have ever had the unpleasure of staying in.. Most times the RN would translate everything for me..

  6. "wrangle an cat"

    Surely this is my imagination... Undoubtedly, if I check again tomorrow, this alleged error will be gone without a trace, and there will be no reason to believe it was ever there to begin with...


  7. Sure must suck to be Ervin. He sounds like a most unhappy miserable person. I can't imagine the amount of energy he uses to be so nasty and disagreeable constantly. What a waste of everyone's time, including his. To bad he has made decisions to be this way.

    1. I'm sure he spends a lot of time by himself when he can rest up between confrontations.

    2. Sounds more like a formal psychiatric disorder. Surely there comes a point where this kind of behaviour merits medical treatment.

    3. thanks to some politicians' utter resistance to helping the little people, there is a big difference between meriting treatment and getting treatment. - and even more so if you don't admit you need treatment.

  8. Sounds like a guy I knew in high school. Only that guy was more like 110 POUNDS, so keeping him in check was fairly easy.

  9. I mean... Sounds like this is the sort of guy that is a good candidate for some Ativan/Haldol. I recognize that violent patients are a risk to healthcare providers but unless we are prepared to kick him out the door we still need to provide care as best as we can. I would get like a bunch of guys to restrain + immobilize a limb and give that IM. Afterall, what if he didnt quiet down in the CT and kept turning his head? What are you gonna do then?

    Tl;dr just sedate the guy abit so that you can get a semi-decent assesment

  10. Ativan/haldol -- the venerable B-52 (often with a snort of Benadryl included).

    Folks are using IM ketamine, with or without Ativan, more and more for this sort of thing. And yes, if the patient is dangerous to himself and others I'm pretty free with sedation.


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